Ocular Allergy Ranges Ocular Allergy: an Updated from the Simplest Measures to the Most Complex Pharmacotherapy, Review Immunotherapy and Monoclonal Antibodies [6]

Journal of Allergy and Immunology Review Article Open Access will be discussed later. The management of ocular allergy ranges Ocular Allergy: an Updated from the simplest measures to the most complex pharmacotherapy, Review immunotherapy and monoclonal antibodies [6]. This manuscript highlights the classification of ocular allergy Buraa Kubaisi1,2, Khawla Abu Samra1,2, Sarah Syeda1,2, Alexander and provides details on the management options of ocular allergy Schmidt1,2* and Stephen C. Foster1-3 that include style modifications and the use of topical and systemic 1Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA medications. In addition the manuscript provides some insight on the use 2Ocular Immunology and Uveitis Foundation, Waltham, MA, USA of immunotherapy in the treatment of the most severe forms of ocular 3Harvard Medical School, Boston, MA, USA allergy and the recent advance in the use of monoclonal antibodies. *Corresponding author: Alexander Schmidt, Email: [email protected] Classification Received: 27 October 2016; Accepted: 13 January 2017; Published: 20 As mentioned earlier, the conjunctiva is the most common ocular January 2017 structure to be involved in ocular allergy, hence allergic conjunctivitis is used interchangeably. The traditional classification methods of allergic Abstract conjunctivitis stems from the cause of the ocular allergy, and can be described as seasonal and perennial allergic conjunctivitis, vernal Ocular allergy encompasses an inflammatory reaction of the keratoconjunctivitis, and atopic keratoconjunctivitis, and giant papillary surface of the eye that is caused by inappropriate response of the conjunctivitis. ocular surface to various environmental allergens. Since the majority of this inflammation involves the conjunctiva, the term “allergic Seasonal Allergic Conjunctivitis (SAC) and Perennial conjunctivitis” is often used interchangeably with ocular allergies. Allergic Conjunctivitis (PAC) Ocular allergy is a common problem that affects people of all ages in which the presentation may vary from being asymptomatic in SAC and PAC comprise most of the allergic conjunctivitis cases mild cases to serious and vision threatening inflammation in severe (about 95% in the United States) [7]. Although SAC and PAC are the cases. Subsets of ocular allergy include the predominantly ocular most common, the proportion of the more severe forms of ocular allergic itch-inducing seasonal allergic conjunctivitis (SAC), and perennial disease (AKC, VKC) increase in countries in the southern hemisphere allergic conjunctivitis (PAC) to more severe sight-threatening vernal [8]. Theories to explain this include increasing levels of industrialization keratoconjunctivitis (VKC), and atopic keratoconjunctivitis (AKC). and pollution or simply an anomaly arising from under-reporting of milder conditions [8]. The management of allergic conjunctivitis ranges from simple life style modifications and the regular use of pharmacologic therapy both SAC and PAC are distinguished from each other mainly by the topical and systemic, to more advanced therapy including allergen timing of exacerbations that could be related to different stimulating specific immunotherapy and a newly introduced anti-IgE antibody allergens in each [9]. SAC (commonly called hay fever conjunctivitis) novel therapy. is more common than PAC and worse during spring and summer times. The most frequent allergens responsible are mold spores or tree, weed, Keywords: Ocular allergy; Allergic conjunctivitis; Seasonal; or grass pollens, however the specific allergen varies with geographic Perennial; Vernal; Atopic location [4]. PAC causes symptoms throughout the year, generally Introduction worse in the autumn when exposure to house dust mites, animal dander, feathers and fungal allergens is greatest. It is less common and tends to Ocular allergy affects up to 40% of the population in the United be milder than the seasonal form [10,11]. The hallmark symptoms of States where allergic conjunctivitis considered the most common both SAC and PAC are itching and redness that are usually bilateral. cause of conjunctivitis Patients living with symptoms of ocular allergy Other symptoms include burning sensation and watering or sometimes endure a lower quality of life secondary to ailments that can range from mild mucoid discharge [10]. The conjunctivae are usually mildly ocular discomfort to vision loss [1,2]. Patientsmayalso suffer from the injected with various levels of chemosis [11]. Although the symptoms financial burden inflicted by the need for adequate management, which are usually bilateral, the degree of involvement may not be symmetric. can be life-long [2]. Furthermore, the global prevalence of ocular Cobblestoning is a sign generally not observed in the SAC or PAC allergies has steadily been on the rise, elevating the burden of this and indicates a more chronic and severe form of allergic conjunctivitis disease on the society [3]. although fine papillary hypertrophy of the upper tarsal conjunctiva Ocular allergy is often associated with nasal allergy symptoms, may occur [12,13]. The cornea is not usually involved in SAC or PAC [11,12]. hence the term ‘rhinoconjunctivitis’. Sixty four percent of patients with symptoms of allergic rhinitis report associated conjunctival symptoms Vernal Keratoconjunctivitis (VKC) of ocular allergy [4]. VKC is a more serious and potentially sight threatening form of A study of patients with hay fever found that ocular symptoms ocular allergy in which the stimulant (allergen) is usually not known alone were experienced in 8% of the study population, while 85.3 [14]. It is a chronic bilateral disease that typically affects young males % of the study population has a combination of both eye and nasal and usually resolves after puberty [14,15]. There is a history of eczema symptoms [5]. or asthma in 75 % of the patient [16]. VKC has a wide geographical Since the majority of the ocular allergic inflammation involves distribution, and usually occurs in warm, dry areas [17]. the conjunctiva, the term “allergic conjunctivitis” is often used KC can be classified to Palpebral, limbal and mixed forms. Palpebral interchangeably with ocular allergies [1,2]. Disorders that fall under form primarily involves the upper tarsal conjunctiva and may be the category of allergic conjunctivitis range from predominantly associated with significant corneal involvement as a result of the close ocular itch-inducing seasonal allergic conjunctivitis (SAC), and perennial allergic conjunctivitis (PAC) to more severe potentially sight-threatening Vernal keratoconjunctivitis (VKC), Atopic Copyright © 2017 The Authors. Published by Scientific Open Access Journals LLC. keratoconjunctivitis (AKC), as well as some other disorder that Kubaisi et al. Volume 1, Issue 1 J Allergy Immunol 2017; 1:002 apposition between the inflamed conjunctiva and the corneal epithelium the above mentioned ocular syndromes and considered part of the [16,18]. Limbal form typically affects black and Asian patients and differential diagnosis include both contact blepharo-conjunctivitis and is usually limited to the perilimbal area. Mixed VKC basically has phlyctanular keratoconjunctivitis features of both palpebral and limbal disease [16,18]. Patients usually have a year-round disease but seasonal flare-ups are common. The Contact Blepharo-Conjunctivitis main symptom of VKC is itching. Other common symptoms include This refers to the acute or subacute reaction that is seen most tearing, mucus discharge, photophobia, pain, burning and foreign body commonly as a reaction to eye drop constituents or sometimes as a sensation [16,18] The signs are mostly confined to the conjunctiva reaction to contact lens solutions [24]. It usually happens in the early and cornea, while the eyelid skin is relatively uninvolved [18] The course of treatment but can be seen after chronic use of the same drop. hallmark finding of VKC is the cobblestone-like giant papillae of the The signs predominantly involve the eyelid skin (erythema, thickening, upper tarsal conjunctiva [16,18,19]. induration), although there may be a conjunctival reaction [24]. It Bulbar conjunctiva is usually edematous and injected. The peri- appears that the preservative may be largely responsible for allergic, limbal conjunctiva may be thickened and edematous forming a toxic or inflammatory reactions, although antiglaucoma and antibiotic gelatinous-like hypertrophy [18] Limbal nodules and Trantas dots drops are not uncommon causes [24]. composed of eosinophils and dead epithelial cells may be observed Phlyctenular Keratoconjunctivitis (PKC) [16]. These limbal changes may sometimes lead to superficial neovascularization of the cornea and pannus. The most important and PKC is a nodular inflammation of the conjunctiva or cornea vision threatening complications occur in the cornea as mild epithelial that results from a hypersensitivity reaction to a foreign antigen. keratitis or in more severe cases as shield ulcers. [16,18] A shield ulcer Conjunctival involvement is usually transient and asymptomatic, but results from chemical damage to the epithelial surface by mediators corneal involvement can occur in various forms and can lead to visual released from mast cells and eosinophils. Shield ulcers are typically impairment. In the past, tuberculin protein was thought to be the main oval or pentagonal, superficial, and superiorly located with grayish antigen responsible for PKC, however, with improvement of public opacification

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